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Project submission form for ho... Project Submission Form for Hospitals Facility identifying information All sections of this form must be completed. Altered forms will not be accepted Facility name Street address City IL Project identifying information ZIP code IDPH Number Project name Type of project new/replace facility renovation/update to existing facility addition to existing facility PPS rehab unit PPS psychiatric unit Safety Net/Community hospital grant Type of submission design development drawings first stage construction/working drawings second stage Total gross square footage of project area Number of beds acute mental illness beds present proposed change ICU beds long term acute care beds long term care beds medical/surgical beds neonatal beds obstetric beds pediatric beds rehabilitation beds TOTAL Form Number 443086 rev 12-2017 Page 1 of 7 IF THIS PROJECT CHANGES THE FACILITY S LICENSED BED COUNT BY ADDING OR REDUCING BEDS IT WILL BE NECESSARY TO CONTACT THE HEALTH FACILITIES AND SERVICES REVIEW BOARD. Certificate of Need Submit a copy of the approved certificate of need CON. A review by the Department WILL NOT begin until a CON or appropriate documentation is received* Written documentation from the Health Services and Review Board may be requested indicating a CON is not required* CON project number Date approved Is this a phased occupancy project Yes No If yes attach an occupancy schedule describing the rooms to be occupied in each phase with a small scale graphic plan Mail completed submission to Illinois Department of Public Health Design and Construction Section 525 W* Jefferson Street Fourth Floor Springfield IL 62761 For questions please call 217-785-4264 Drawing submission Provide one set of signed/sealed drawings and outline specifications for review in accordance with Section 250. 2430 of the Illinois Hospital Licensing Requirements. This includes design development drawings and outline specifications and working/construction drawings and specifications. Drawings are not to exceed 30 x 42. Estimated project cost 1. Site preparation costs 2. Demolition costs 3. Construction contracts including cost of materials 4. Change orders Subtotal - lines 1 thru 4 6. Fixed capital equipment Add lines 5 and 6 If the fixed capital equipment is not more than 51 percent of the total cost then use line 7 for the plan review fee calculation below. 8. If line 6 is 51 percent more than line 7 then multiply line 6 by. 20 Place the total adjusted estimated project cost in the appropriate estimated project cost category listed below. diagnostic equipment MRI scanners X-ray equipment etc. Equipment which is part of the building such as AHU boilers chillers lights fire alarm panels and all related components are to be included in the construction costs. Plan review fee calculation The plan review fee is due and payable upon submission of this form along with the drawings and required information* Using the figures in line 7 or line 9 whichever is applicable calculate the plan review fee.

Town of cary project modificat... Application/Permit # - PROJECT MODIFICATION This form must be completed for all projects whenever you wish to change the scope of work as described on the original application. PROJECT INFORMATION

Title of example project from... G. KEY PERSONNEL PARTICIPATION IN EXAMPLE PROJECTS 26. NAMES OF KEY PERSONNEL (From Section E, Block 12)27. ROLE IN THIS CONTRACT (From Section E, Block 13)28. EXAMPLE PROJECTS LISTED IN SECTION F (Fill

Project ority form 1346910 REQUISITIONER11. DATE3035363971415F. SUPPLEMENTARY ADDRESS 4550 44DOCUMENT IDENTIFICATION 18F. DISTRIFUND BUTION 51 5253 545616F. SIGDOCUMENT NUMBER13. DEMDOC. IDEN.2. 3. ROUTING IDEN.M&S1.17.19.20. 21. REQ\'D PRIDELIVERY PROJECT

Project and city form ORIGINATING OFFICEESTIMATE WORKSHEETDATE SUBMITTEDPROJECT AND CITYPROJECT NUMBERCONTRACT NUMBERPURPOSE ITEMESTIMATE VALID TO:ESTIMATED BYDATE SHEET NO. MATERIALQUANTITY DESCRIPTION OF WORKNO. UNIT UNITS

Star project numberlocation fo... STAR PROJECT NUMBER:LOCATION:OA NUMBER:AGENCY:LEASE NUMBER:CBR NUMBER:LOCATION CODE:SQUARE FOOTAGE:BROKER CONTRACT NO.TASK ORDER NO.CONTRACT LEASING AGENT:PHONE NUMBER:CONTRACTING OFFICER:I. REQUIREMENTRequiredNot

F example projects which best... F. EXAMPLE PROJECTS WHICH BEST ILLUSTRATE PROPOSED TEAM\'S QUALIFICATIONS FOR THIS CONTRACT (Present as many projects as requested by the agency, or 10 projects, if not specified. Complete one Section

All volunteers that participat... GROUP NAME:OMB no. 05960080 DATE:AGENCY NAME:Volunteer Service AgreementNatural & Cultural ResourcesVolunteer Signup Form for GroupsAll volunteers that participate with an organized group on an episodic

Fbf project allowance form FBF PROJECT ALLOWANCE I. GENERAL FUNDALLOWANCE NO. REGIONB/A NO.FISCAL YEARNEAR ACTION CODE*NO. APPROPRIATION TITLE AND SYMBOLISSUED TOINITIALBUDGET ACTIVITYBUILDING NUMBERINCREASEBUILDING NAME AND

Project cost comparison summar... PROJECT COST COMPARISON SUMMARY Project:Project No:Location:Estimator:Construction Cost (ECCA) (Level 2) 01FOUNDATIONS02SUBSTRUCTURE03SUPERSTRUCTURE04EXTERIOR CLOSURE05ROOFING06INTERIOR CONSTRUCTION07CONVEYING

Project management and global... SUSTAINABILITY IN PROCUREMENT FELLOWSHIP PROJECT SUBMISSION Projects submitted for consideration for the Sustainability in Procurement Fellowship Program should: * Have clearly defined project goal(s),

Eagle scout service project wo... The committee and the council or district before you start. You must use the Eagle Scout Service Project Workbook No. 512-927 in meeting this requirement. Project expectations will match Eagle Scout requirement 5 and we will not require proposals to include more than described in the Eagle Scout Service Project Workbook. Eagle Scout Service Project Workbook Eagle Scout candidate s full legal name Please give a name to your project October 2015 Message From the Chief Scout Executive Greetings Eagle Scout Candidate Congratulations on earning the rank of Life Scout. You must use the Eagle Scout Service Project Workbook No. 512-927 in meeting this requirement. In addition to providing service and fulfilling the part of the Scout Oath To help other people at all times one of the primary purposes of the Eagle Scout service project is to learn leadership skills or to improve or demonstrate leadership skills you already have. You are among approximately 57 000 young men who year after year achieve that important milestone. As you ponder the meaning behind the Life patch I encourage you to think about the symbol of the heart. Historically in Scouting it was a fitting symbol of health and fitness but it also represents the spirit of caring and giving that s behind the Eagle Scout service project. Service to other people is what Scouting is all about. In many ways your should be of significant impact in your community to be special and should represent your very best effort. Your proposal the logical first step should emphasize your intention to give leadership to others through proper planning and development. Communicate with the beneficiary often to ensure the project meets the organization s needs once it s completed* Scout Service Project Workbook much like a compass will help navigate your way to a life of service as a proud Eagle Scout. Wishing you all the best in your journey on the Trail to Eagle Michael B. Surbaugh Chief Scout Executive Scouts and Parents or Guardians Please read Message to Scouts and Parents or Guardians on pages 5 and 6. This includes excerpts and summaries from the Guide to Advancement that may help ensure requirements are properly administered according to national BSA policies and procedures. Please note also that when a Scout submits his project proposal he will promise he has read this entire workbook. Doing so will be important to his success. Only the Official Workbook May Be Used found at www. scouting. org/advancement. Although it is acceptable to copy and distribute the workbook no council district unit or individual has the authority to produce or require additional forms or to add or change requirements or to make any additions deletions or changes in the text outlines links graphics or any other elements of the workbook. Attention Unit District and Council Reviewers Eagle Scout projects must be evaluated primarily on impact the extent of benefit to the religious institution school or community and on the leadership provided by the candidate.

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